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Renal and Retinal Effects of Enalapril and Losartan in Type 1 Diabetes
Renal and Retinal Effects of Enalapril and Losartan in Type 1 Diabetes
onary artery disease in the Coronary Artery Surgery Study invite indirect comparisons between PCI and CABG
(CASS). J Am Coll Cardiol 1993;22:1141-54.
5. Gavard JA, Chaitman BR, Sakai S, et al. Prognostic signifi- among physicians faced with the clinical decision
cance of elevated creatine kinase MB after coronary bypass sur- of which choice of revascularization is best suited
gery and after an acute coronary syndrome: results from the for a given patient, particularly if the goal of revas-
GUARDIAN trial. J Thorac Cardiovasc Surg 2003;126:807-13.
cularization is to reduce long-term clinical events
(especially myocardial infarction). Our recommen-
The Editorialists Reply: Garratt and Bailey dation that CABG surgery is the preferred approach
suggest that our statement that CABG surgery is to revascularization in patients with diabetes and
the preferred approach to revascularization in pa- stable coronary disease is further supported by
tients with diabetes and stable coronary disease two other randomized trials1,2 and a recent meta-
was not factual. We respectfully disagree. We clear- analysis.3
ly emphasized that among such patients who re-
mained symptomatic despite intensive treatment William E. Boden, M.D.
or who had substantial ischemia or extensive cor- State University of New York at Buffalo
onary artery disease, revascularization with either Buffalo, NY
PCI or CABG was reasonable and appropriate. We David P. Taggart, M.D., Ph.D.
explicitly acknowledged that the BARI 2D design Oxford University
precluded any direct comparison between PCI and Oxford, United Kingdom
CABG with regard to clinical outcomes. However, 1. BARI Investigators. The final 10-year follow-up results from
we reasoned that the option of either PCI or the BARI randomized trial. J Am Coll Cardiol 2007;49:1600-6.
CABG for revascularization, depending on the ana- 2. Serruys PW, Morice M-C, Kappetein AP, et al. Percutaneous
coronary intervention versus coronary-artery bypass grafting for
tomical complexity of coronary disease, is a real- severe coronary artery disease. N Engl J Med 2009;360:961-72.
world strength of the trial. In addition, the signifi- 3. Hlatky MA, Boothroyd DB, Bravata DM, et al. Coronary ar-
cant reduction in the composite end point (death, tery bypass surgery compared with percutaneous coronary inter-
ventions for multivessel disease: a collaborative analysis of indi-
myocardial infarction, or stroke) in patients with vidual patient data from ten randomised trials. Lancet 2009;
diabetes who underwent CABG would inevitably 373:1190-7.
tensin system in patients with type 1 diabetes did sion is an important precondition for early mes-
not slow nephropathy progression but slowed the angial expansion. In fact, earlier studies strongly
progression of retinopathy. These findings may suggested that hypertension in patients with type
stimulate the widespread use of blockers of the 1 diabetes is more likely the consequence than
renin–angiotensin system in normotensive pa- the cause of mesangial expansion.1 Nevertheless,
tients with type 1 diabetes and normoalbuminu- the results of the Renin–Angiotensin System
ria. However, a higher incidence of microalbu- Study (RASS) should not be extrapolated to the
minuria in the losartan group, which had the relatively uncommon circumstance of patients
best retinopathy outcome, raises concern about with diabetes, normoalbuminuria, normal or in-
possible adverse renal effects of blockade of the creased glomerular filtration rate, and systemic
renin–angiotensin system in these patients. Do hypertension. The fact remains that the large
we have to trade nephropathy for retinopathy? majority of patients with diabetes and normoal-
Further studies are warranted, but a closer look buminuria are normotensive, and renal benefits
into the data in the study by Mauer et al. might from blockade of the renin–angiotensin system
help clarify this question. For instance, the renal could not be demonstrated in such patients. If
outcomes of patients without retinopathy pro- precise early predictors of diabetic nephropathy
gression in each group should be compared. Un- become available, new studies including only pa-
til more data are available, we would think that tients at high risk would be warranted. In regard
blockade of the renin–angiotensin system in to the suggestion by Katavetin and Katavetin
normotensive patients with type 1 diabetes and about patients without retinopathy progression,
normoalbuminuria, even with angiotensin-con- the RASS does not have sufficient power for this
verting–enzyme inhibitors, should not be gener- kind of subanalysis. We agree that further stud-
ally recommended. ies are warranted.
Pisut Katavetin, M.D. Michael Mauer, M.D.
Chulalongkorn University University of Minnesota
Bangkok, Thailand Minneapolis, MN
pkatavetin@yahoo.com mauer002@umn.edu
Paravee Katavetin, M.D. Bernard Zinman, M.D.
Thonburi Hospital
University of Toronto
Bangkok, Thailand
Toronto, ON, Canada